Provider Demographics
NPI:1588075725
Name:RICHMOND, SUSAN ELIZABETH
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:ELIZABETH
Last Name:RICHMOND
Suffix:
Gender:F
Credentials:
Other - Prefix:MISS
Other - First Name:SUSAN
Other - Middle Name:ELIZABETH
Other - Last Name:SHEPHERD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:10510 GRAVELLY LAKE DR SW
Mailing Address - Street 2:
Mailing Address - City:LAKEWOOD
Mailing Address - State:WA
Mailing Address - Zip Code:98499-5036
Mailing Address - Country:US
Mailing Address - Phone:253-589-7033
Mailing Address - Fax:253-589-7033
Practice Address - Street 1:10510 GRAVELLY LAKE DR SW
Practice Address - Street 2:
Practice Address - City:LAKEWOOD
Practice Address - State:WA
Practice Address - Zip Code:98499-5036
Practice Address - Country:US
Practice Address - Phone:253-589-7033
Practice Address - Fax:253-589-7033
Is Sole Proprietor?:Yes
Enumeration Date:2014-05-09
Last Update Date:2019-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADH 00005991124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist